Year 1 CMS Diagnosis and Exams PDF

YEAR 1 CMS RESPIRATORY TRACT INFECTIONS (SORE THROAT) Red flag diagnoses in red * = sometimes Temperatur e Fever - A Toxic appearance Acute Epiglottis Fever Peritonsilar Abscess Fever Retropharyngeal Abscess Fever Streptococcal Pharyngitis Oropharyngeal Exam Dysphagia Drooling Dysphonia Distress Inf...

YEAR 1 CMS RESPIRATORY TRACT INFECTIONS (SORE THROAT) Red flag diagnoses in red * = sometimes Temperatur e Fever - A Toxic appearance Acute Epiglottis Fever Peritonsilar Abscess Fever Retropharyngeal Abscess Fever Streptococcal Pharyngitis Oropharyngeal Exam Dysphagia Drooling Dysphonia Distress Inflammation of epiglot. *DO NOT USE TONGUE DEPRESSOR Dysphagia, odynophagia leading to pooling of saliva Fetor breath - dDsphonia Unilateral erythematous, enlarged tonsil Exudate Uvular deviation to contralateral side Drooling Dysphonia Bulging of posterior wall of oropharynx Dysphagia Edema and erythema of tonsils and pharynx Nasal Exam Cervical Lymph Nodes Eye Exam Lung Exam Severely tender lymph nodes Ispilateral otalgia Neck stiffness Enlarged and tender anterior cervical lymph nodes Abdominal pain symptom (do not do abd. Exam) Infectious Mononucleosis Low-grade fever Afebrile or low-grade fever Non-adherent tonsilar/phharyngeal exudate Palatine petechiae* Tonsillar exudates Palatine petechiae Posterior oropharynx mildly inflamed and erythematous Fever Sore throat Common Cold Influenza Nasal congestion Rhinorrhea Nasal turbinates erythematous and swollen Nasal congestion Rhinorrhea Erythema Edema Posterior cervical lymphadenopathy Posterior cervical lymph nodes enlarged and tender Splenomegaly* (Inspecting the eyes for conjuntivitis) (Lung exam woulf be normal in a common cold) HEARING LOSS/OTALGIA * = sometimes Sensorineural Hearing Loss Otitis Externa (with conductive hearing loss) Weber Test Lateralization to unaffected side Lateralization to affected side Rhinne Test AC > BC BC > AC Ear Exam Pruritus, fullness Otorrhea* Pain on movement of Tragus, auricle (pinna) Erythematous, oedematous, inflamed external ear canal Cervical Lymph Nodes Periauricular lymphadenopathy Temperature Otitis Media (with conductive hearing loss) Lateralization to affected side BC > AC Otalgia Otorrhea* Bulging, cloudy/erythematous, immobile tympanic membrane with obscured bony landmarks Fever JOINT PAIN * = sometimes Temperature Fever* Septic Arthritis Gout Pseudogout Rheumatoid Arthritis Osteoarthritis Knee Exam Pain Edema Erythema Warmth Immobility Morning pain/stiffness Erythema Tophi* on pre patella bursae Morning pain/stiffness Symmetrical pain and stiffness Morning stiffness Boggy swelling Palpable synovial thickening Pain with pressure, movement Asymmetric joint pain/stiffness Swelling Nutritional Status Exam Gait Assessment Keratoconjunctivitis sicca (dry eyes) Episcleritis/scleritis Joint locking or instability Pain worse with movement Tenderness Bony enlargement (prolonged or severe) Pain on ROM, limited ROM Crepitus LOW BACK PAIN/RADICULOPATHY = sometimes Dermatomes L2, L3, L4 Radiculopathy L5 Radiculopathy S1 Radiculopathy Paresthesia of anterior thigh, *medial calf* Paresthesia of lateral thigh, lower lateral leg, dorsum of foot Paresthesia of sole, lateral foot and ankle, fourth and fifth toes Myotomes Weak knee extension, hip adduction, hip flexion Weak big toe extension, foot eversion and inversion, ankle dorsiflexion, hip abduction Weak plantar flexion Reflexes Gait Assessment Straight Leg Raise Asymmetric medial hamstring reflex Foot drop and inability to walk on heels Positive (reproduction of pain at 30-60 degrees) Asymmetric ankle reflex Heel drop and inability to walk on toes Positive (reproduction of pain at 30-60 degrees) Asymmetric patellar reflex Femoral Stretch Test Positive (reproduction of pain in anterior thigh) ABDOMINAL PAIN = sometimes Temperatur e Fever Appendicitis Bowel Obstruction Abdominal Aortic Aneurism Mesenteric Ischemia Abdominal Exam Right lower quadrant pain on palpation Migrating from periumbilical area to right lower quadrant Rebound tenderness Rigidity McBurney’s point painful on palpation Distention Increased bowel sounds Pulsatile abdominal mass Aortic bruit? Pain on palpation Postprandial pain Nutritional Status Exam Blood Pressure Skin turgor test may show dehydration (if bowel obstruction is caused by constipation) Hypotension Dermatological Exam Ectopic Pregnancy Ovarian Torsion Pelvic Inflammatory Disease Fever, chills Peptic Ulcer Disease Fever Cholecystitis Nephrolithiasi s Acute Pancreatitis Low-grade fever Chronic Pancreatitis Fever* Diverticulitis IBS Severe lower quadrant pain (stabbing, intermittent, does not radiate) Pelvic adnexal mass* Severe unilateral pain (usually rightsided) Mild, intermittent* Tenderness and guarding on palpation Latero-uterine mass Lower abdominal pain Adnexal tenderness Dyspepsia (upper abdominal discomfort) Pallor on assessment of conjunctival rim (anemia) Murphy’s sign positive Right upper quadrant pain Eyes may appear yellow (jaundice) on assessment of conjunctival rim Excruciating back and flank pain radiating to abdomen or groin Pain radiates to back* Pain exacerbated in supine position Guarding on palpation Periumbilical bruising Flank bruising* Disabling mid-epigastic prostprandial pain Pain radiates to back Relieved by sitting forward Bloating* Left lower quadrant tenderness Abdominal distention Rigidity on palpation Pain Unintentional weight loss Skin may appear yellow (jaundice) Bloating EPIGASTRIC/RETROSTERNAL PAIN Temperatur e Abdominal Exam Epigastric burning GERD Barrett’s Esophagus Epigastric pain Gastritis Peptic Ulcer Disease SIBO Fever Chron’s Disease Epigastric pain Dyspepsia Dyspepsia (upper abdominal discomfort) Pain Bloating Pain My have cramping on palpation Oropharyngeal Exam Sour taste in mouth Dysphasia Sore throat Hoarseness Globus sensation Dysphagia Joint Exam Nutritional Status Exam Evidence of inflammato ry arthrothapi es (edema) Pallor (indicating anemia) or episcleritis on assessment of conjunctival rim Pulse Dermatological Exam Belching Aphthous Stomatitis (ulcers in mouth) Finger clubbing Hyperactive bowel sounds Tender on palpation Hyperactive bowel sounds Hyperactive bowel sounds (diarrhea) Ulcerative Colitis Fever C. Difficile Ulcers in mouth Finger clubbing Skin turgor test may show dehydration (due to diarrhea) Signs of malnutrition* (ex. Pallor on assessment of conjunctival rim) Weight loss* Bloating (notable absence of pain) Celiac Disease NonCeliac Gluten Sensitivity Bloating Pain Aphthous Stomatitis (ulcers in mouth) Tachycar dia May have joint pain Dermatitis herpetiformis: Symmetric vesicles (may coalesce), crusts, erosions, distributed over extensor surfaces Rash EATING DISORDERS Heart Auscultation Arrhythmia Anorexia Nervosa Pulse Bradycardia Blood Pressure Hypotension Oropharyngeal Exam Dermatological Exam Brittle hair Brittle nails Hyperkeratosis Lanugo (thin layer of hairs over skin) Cervical Lymph Node Exam Hyppotension Bulimia Nervosa Dental erosions/gum disease Scars or calluses on fingers or hands Enlarged parotid gland Pallor Brittle hair Brittle nails Hair loss Cold Avoidant/Restric tive Food Intake CARDIOVASCULAR DISEASE = sometimes Blood Pressure Myocardial Infarction Hypotensi on Heart Auscultation Lung Auscultation Third heart sound Palpitations Crackles Endocarditi s Myocarditi s Pericarditis Vitals Peripheral Edema/Pul ses Dyspnea Abdominal Exam Nutritional Status Exam JVP Elevate d Fever Palpitation Third heart sound Murmurs Pericardial friction rub Dyspnea Syncope Pleural effusion (muffled sound) Tachycardia Pulsus paradoxus (decrease BP on inspiration) Fever* (if infectious) Edema present Elevate d Distenti on Aortic Dissection Asymmetr ic BP in upper extremitie s Asymmetri c pulses in upper extremities Tachycardia Dyspnea Pulmonary Embolism Cardiac Arrhythmi a Heart Failure Palpitations Laterally displaced apical impulse S3 heard Dermatomes Numbness in lower limb Dyspnea Tachycardia Crackles Myotomes Muscle weakness in lower limb Peripheral Vascular Disease Deep Vein Thrombosis Paralysis or paresis of affected leg Pain in chest, back or abdomen (intense, ripping) Pale nail beds, palms of hands (ischemia) Edema present (deep vein thrombosis ) Irregular pulses Pulsus alternans Edema present Dermatological Exam Ulcers on nonhealing wounds Skin feels cool Pallor, cyanosis Nails appear brittle, rigid Collateral superficial veins visible Cool too touch Elevate d Pulses Palpable pulse abnormality Bruits Peripheral Edema Femoral artery bruit (or any lower limb bruit) Pitting edema Calf swelling > 3 cm compared to unaffected leg or entire leg swollen YEAR 2 CMS METABOLIC DISEASES NAFLD Liver Paplation Mild discomfort on palpation Palpable liver edge Obesity Palpable liver edge if comorbid NAFLD Hepatic Fibrosis/Cirrh osis Pain on palpation Non-palpable edge or hardened edge Tumour may be palpable Hepatocellula r Carcinoma Liver Failure Liver Span Hepatomegal ymidclavicular liver span > 10cm Hepatomegal ymidclavicular liver span > 10cm if NAFLD Liver smaller than previous measurement s if severe Anthropometri c Measures Typically obese BMI >30 kg/m2 WC > 102 cmm (men), >88 cm (women) BMI > 30kg/m2 WC > 102 cmm (men), >89 cm (women) NC > 40 cm Skin/Nails Exam Signs of malnutritio n (pallor) Jaundice Bruising/pet echiae Spider angiomas Caput medusae Palmar erythema Fatty deposits around the eyes Fluid Wave Test May be elevated (metabolic syndrome) May be positive for ascites Hypertension (>140/90 mmHg) Negative for ascites Edema Peripheral edema Jaundice Jaundice Jaundice Skin Exam Vitals Opthalmoscopic Exam Positive for ascites Neuro Exams Oropharyngeal Exam Diabetes Acanthosis nigricans Eruptive xanthomas Unhealing wounds in periphery Cotton wool spots Edema Diplopia (snell chart) Ipswitch test Sharp/dull discrepancy Vibration sensation Oral candidiasis (thrush) more common in diabetes patients SHOULDER PATHOLOGIES Rotator Cuff Tendinopathy/ Impingement Supraspinatus Inspection/Palpati on Muscle wasting (if severe/chronic) Pain on palpation of supraspinatus tendon (directly below acromion) Infraspinatus Pain on palpation of infraspinatus tendon (posterior to supraspinatus) Teres minor Pain on palpaation (posterior and inferior to supraspinatus) May or may not have pain on Subscapularis ROM External Rotation Lag AROM pain on abd RROM weakness on abd Positive (arm drops) in full thickness tear AROM might have pain on lat rot (usually painless) AROM weakness on lat rot AROM pain on lat rot RROM weakness on lat rot Positive (arm drops) in full thickness tear AROM pain on med rot RROM weakness on med rot Internal Rotation Lag Positive in full (obvious drop) or partial thickness Painful Arc Drop-Arm Pain between 60-120° of abduction suggests impingement Pain suggests partial thickness tear Drop of the arm/weakne ss suggests fullthickness tear Pain and/or weakness Adhesive capsulitis Shoulder Instability/Dis location palpation (not palpable) Swelling Abnormal bony prominence Usually anterior dislocation Patient holds the arm in externally rotated position (subtle drop) tears Limited AROM and PROM (especially lat rot and abd) Clicking or popping on PROM Limited ROM 9unless persistent instability) THYROID DISORDERS Vitals Hypothyroidis m Bradycardia Bradypnea/dy spnea Diastolic hypertension Myxedema Hypothermia Hypotension Bradycardia Hypoventilati on Altered mental status Thyroid Exam Goiter on inspection/pa lpation Goiter on inspection/pa lpation Neuro Exam Delayed or diminished DTRs Muscle weakness (myotomes) Delayed or diminished DTRs Muscle weakness (myotomes) Skin/Hair/Nail s Exam Xeroxes Dry, thinning hair Thin, brittle nails Puffy face, eyelids Pallor Xeroxes Dry, thinning hair Thin, brittle nails Puffy face, eyelids Pallor Anthropometri c Measures Elevated BMI Peripheral Edema Non-pitting edema Elevated BMI Non-pitting edema Heart Auscultation Arrhythmias FATIGUE Rule out Condition s Lymph Nodes Swollen and/or tender in head/neck region indicates infectious cause Swollen and/or tender in axillary region may suggest cancer Abdomin al Exam Palpable mass may indicate cancer Decrease d/absent bowel sounds may indicate obstructio n from mass Oropharyngeal Exam Palatine patechiae indicate mononucleosis Enlarged tonsils/tongue (Mallampati > class II = high risk for sleep apnea) Liver/Spleen Palpation Splenomegal y indicates mononucleos is or hemolytic anemia Hepatomegal y may indicate hepatitis Heart Ausc Lung Ausc Vitals S3 indicates heart failure/arr hythmias/ endocardit is Abnormal breath sounds may indicate COPD, pneumonia, tuberculosis Look for: Hypotensi on Dyspnea Diminishe d pulses Neuro Exam Weaknes s in myotome s may indicate MS Weaknes s/tremors may indicate Parkinso n’s Skin Exam Pallo r may indic ate anem ia *See hypothyroid INSOMNIA Consider OSA Consider GERD Anthropometric Measures BMI > 30 kg/m2 (obesity increases risk of OSA) NC > 40 cm increases risk of OSA Oropharyngeal Exam Mallampati score > class II increases risk of OSA Teeth erosion Halitosis Abdominal Palpation Pain in epigastric region Nose and Sinus Exam Lung Ausc Heart Ausc Consider Breathing Problems NC > 40 cm BMI > 30 kg/m2 Deviated septum Erythema/edema Pain on sinus palpation Nonvesicular breath sounds may indicate lung congestion/in fection/occlus ion Consider Heart Failure S3 heard in heart failure PERIPHERAL ARTERY DISEASE Vitals Atherosclerosis Peripheral Artery Disease Hypertensi on (contribute s to atheroscler osis) Diminishe d peripheral pulses Shortness of breath Diminishe d peripheral pulses Abdomina l Palpation Assess for abdominal aortic aneurism (aorta diameter >2.5 cm) Abdomina l aortic aneurism Lung Ausc Heart Ausc Skin Exam Wheezing may indicate pulmonary edema S3 heard in heart failure Xanthomas around the eyes Unhealing wounds on feet Cool skin on lower limb Neuro Exam Peripheral Edema Bruits Carotid and/or abdominal bruits Weakness in lower limb myotomes Numbness in lower limb dermatomes Edema in feet, legs or ankles Carotid and/or abdominal bruits Peripheral Vascular Disease Change in colour of lower limb Slow toenail growth Hair loss on lower limb Varicose veins in lower limb Itchy xerosis on lower limb Abnormal colour of lower limb Cool skin lower limb Diminishe d peripheral pulses Edema in feet, legs or ankles Carotid and/or abdominal bruits SECONDARY HEADACHES Nose Exam Rhinosinusitis Facial pain/pressure Vitals Fever Ophthalmoscopic Exam Ear Exam Cranial Nerve Exam (Any) Skin Exam Bruits on sinus palpation Nasal congestion Rhinorrhea Nasal obstruction Meningitis Fever Sensitivity to light Papilledema Head Trauma Sensitivity to light Blurred vision (snell chart) Subarachnoid Hemorrhage Vision changes (snell chart) Retinal hemorrhages (rare) Sensitivity to light Vision loss Transient visual obscurations Diplopia Papilledema Intracranial Hypertension Sensitivity to sound from tuning fork CSF leakage on otoscopic exam Sensitivity to sound from tuning fork Cranial nerve palsies Rash Postauricular ecchymosis (battle sign) Perioorbital ecchymosis (racoon eyes) Cranial nerve palsies Sensitivity to sound from tuning fork Cranial nerve palsies Olfactory dysfunction Present (idk where) Papilledema PRIMARY HEADACHES CN II CN VIII CN V CN IX CN I Tension-Type Headaches Migraine Weakness/increased pain with resistance to SCM/trapezius Sensitivity to light Vision change in ipsilateral eye Sensitivity to noise from tuning fork Ipsilateral weakness of masseter/temporalis Increased sensitivity on ipsilateral side (ophthalmic, maxillary and mandibular branches) Strong odours may precipitate migraine ANEMIA Skin Exam Iron Deficiency Anemia Bruising/petechi ae Hemolytic Anemia Jaundice Bruising/petechi ae DEMENTIA Castell’s Sign May have splenomegaly Vitals Hair/Nails Tachycardia Dyspnea (on exertion) Brittle hair/nails Tachycardia Dyspnea (on exertion) Brittle hair/nails Nutritional Status Exam Conjunctival rim pallor Palmar crease pallor Palmar pallor Icterus (yellowing of sclera) DRE May have rectal bleeding Bruits Vascular Dementia Carotid and/or abdominal bruits suggest atherosclerosis Any Dementia Delerium Vitals Hypertension Peripheral pulses diminished Gait Assessment Abnormal/shuf fled gait Abnormal/shuf fled Fever Mini Cog CN VIII CN I Score < 3/5 pts Sensorineural hearing loss Diminished sense of smell Score < 3/5 pts Sensorineural hearing loss Diminished sense of smell Low scoring, inattention, unfocused Skin Turgor Dehydration URINARY TRACT INNFECTIONS Acute Cystitis Pyelonephr itis Abdomina l Palpation Suprapubi c pain on palpation Flank pain Kidney Punch Absence of costover tebral angle tenderne ss Costover tebral tenderne ss Vitals Myotomes Mini Cog No fever General weakness (atypical, in elderly) Confusion, delirium (atypical, in elderly) Fever, chills May have very low or very high blood pressure May have tachypnea and/or tachycardia Confusion, delirium (in elderly) Knee Exam Eye Exam Skin Exam DRE Urethritis caused by Reiter’s Syndrome (Reactive arthritis) Acute Bacterial Prostatitis Chronic bacterial prostatitis Low back pain (?) Lower abdominal pain Low back pain (?) Low back pain (?) Pain, swelling Fever, chills Eye redness/irri tation (uveitis/con junctivitis) Burning sensation wth rash on feet Pain, enlarged prostate May be normal